Recommended for all travelers to the states of Meghalaya, Tripura and Mizoram in the northeast

Hepatitis A

Recommended for all travelers

Typhoid

Recommended for all travelers

Polio

One-time booster recommended for any adult traveler who completed the childhood series but never had polio vaccine as an adult

Yellow fever

Required for all travelers arriving from or transiting through a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.

Japanese encephalitis

For travelers who may spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors in rural areas, especially after dusk

Hepatitis B

Recommended for all travelers

Rabies

For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats

Measles, mumps, rubella (MMR)

Two doses recommended for all travelers born after 1956, if not previously given

Tetanus-diphtheria

Revaccination recommended every 10 years

Medications

Travelers' diarrhea
is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either
ciprofloxacin (Cipro)(PDF)
500 mg twice daily or
levofloxacin (Levaquin)
500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of
rifaximin (Xifaxan)
200 mg three times daily or
azithromycin (Zithromax)
500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria
in India: prophylaxis is recommended year-round throughout the country (including the cities of Delhi and Bombay), except at altitudes greater than 2000 m (6561 ft) in the states of Himachal, Jammu, Kashmir, Pradesh, and Sikkim. Most malaria cases are reported from forested areas in the states of Madhya Pradesh, Maharashtra, Orissa, Gujarat, Rajasthan, Bihar, and Karnataka. Either
mefloquine (Lariam)
,
atovaquone/proguanil (Malarone)(PDF)
, or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the
Lariam Medication Guide
(PDF). Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See
malaria
for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Insect protection measures are essential.

Malaria outbreaks have been reported from the northeastern state of Assam for the last two years. See "Recent outbreaks" below.

For further information concerning malaria in India, including a breakdown of cases by states, go to
Roll Back Malaria.

Altitude sickness
may occur in travelers who ascend rapidly to altitudes greater than 2500 meters, which includes the mountainous areas of northern India. Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced.

Travel to high altitudes is not generally recommended for those with a history of heart disease, lung disease, or sickle cell disease.

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF) . Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.

Typhoid vaccine is recommended for all travelers. It is generally given in an oral form ( Vivotif Berna ) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF) , given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Polio immunization is recommended. Any adult who received the recommended childhood immunizations but never received a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. Side-effects are uncommon and may include pain at the injection site. Since inactivated polio vaccine includes trace amounts of streptomycin, neomycin and polymyxin B, individuals allergic to these antibiotics should not receive the vaccine.

Japanese encephalitis vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. Peak transmission occurs from May to October, during and just after the monsoon season. An outbreak was reported from Uttar Pradesh in August 2005 (see "Recent outbreaks" below.) Historically, outbreaks have occurred in Andhra Pradesh every two to three years. Outbreaks have also been reported from West Bengal, Bihar, Karnataka, Tamil Nadu, Assam, Uttar Pradesh, Manipur and Goa. Urban cases have been reported (e.g. Lucknow). In India, the only states not reporting Japanese encephalitis are Arunachai, Dadra, Daman, Diu, Gujarat, Himachai, Jammu, Kashmir, Lakshadweep, Meghalaya, Nagar Haveli, Orissa, Punjab, Rajasthan, and Sikkim.

The recommended vaccine is IXIARO , given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of two months.

Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF) . A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. Dog bites account for most cases of rabies in India. Bites from cats, tigers, camels, and the Indian civet may also transmit rabies. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

All travelers should be up-to-date on routine immunizations, including

Tetanus - diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years; diphtheria reported among children in north India September 1999)

Measles vaccine (recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.)

Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Cholera vaccine is not generally recommended, even though outbreaks occur (see below), because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol) , licensed in Canada and Australia, and Dukoral , licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.

Yellow fever vaccine is required for all travelers greater than six months of age arriving from country in Africa or the Americas with risk of yellow fever transmission, or arriving from or transiting through the following countries:

Any person (except infants up to the age of 6 months) arriving without a certificate within 6 days of departure from or transit through an infected area, or arriving on a ship that started from or touched at any port in an area with risk of yellow fever transmission up to 30 days before its arrival in India, unless such a ship has been disinsected in accordance with the procedure recommended by WHO, will be isolated for up to 6 days.

Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center , which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy. Yellow fever vaccine is not recommended or required for travelers arriving directly from North America, Europe, Australia, or other Asian countries.

An encephalitis outbreak was reported from north Bengal in July 2014, causing over 200 deaths by August. About a quarter of the cases were caused by Japanese encephalitis. The cause of the other cases remains unknown. The largest number of cases was reported from Jalpaiguri district, with rural areas in Dhupguri and Moynaguri particularly affected because of the presence of a large number of pig farms there. As above, Japanese encephalitis vaccine is recommended for long-term (greater than 1 month) travelers to rural areas and travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips.

An outbreak of scrub typhus was reported from Himachal Pradesh in July 2014, particularly affecting Bilaspur district. A total of 137 cases were reported. Before that, outbreaks of scrub typhus were reported from Himachal Pradesh in September 2012, causing hundreds of cases and 28 fatalities, and in September 2013, causing dozens of cases and no fatalities. A fatal case of typhus was reported from Kota district, Rajasthan state, in September 2014. Sporadic cases were reported from Chennai (Tamil Nadu) in the last few months of 2013.

Scrub typhus is transmitted by mites. The disease is characterized by fever, enlarged lymph nodes, rash, and an eschar (scab) at the bite site. The treatment of choice is doxycycline. Most travelers are at low risk.

Cases of scrub typhus were also reported from Wardha district, Maharashtra, in November 2012; from Rajasthan in October 2012, causing at least 14 deaths; from Chandigarh, Mohali, and Panchkula in October 2012; from Kozhikode district, Kerala state, in June 2012; from Chennai and from Erode district, Tamil Nadu, in January 2012; from Pune, Maharashtra, in January 2012 and again in May 2014; from Meghalaya in December 2011; and from Poilwa village, Peren District, Nagaland, and from Mandi district of Himachal Pradesh in March 2011 (see ProMED-mail; March 19 and September 17, 2011, January 21, February 3, and September 23, 2012, May 15, 2014). An outbreak of scrub typhus was reported in December 2009 from the state of Meghalaya, causing more than 80 cases and five deaths. Most of those affected were from the rural areas of West Khasi Hills, East Khasi Hills, and Ri Bhoi (see ProMED-mail , December 17, 2009).

An outbreak of hepatitis E was reported in June 2012 from the textile town of Ichalkaranji in the state of Maharashtra, causing more than 4000 cases and 12 deaths. The outbreak was thought to have been caused by contaminated water from the Panchganga river, which was being used for drinking due to shortages from other sources. In December 2011, a hepatitis E outbreak was reported from the town of Mehsana in the state of Gujarat, probably caused by contamination of the municipal water supply. In July 2011, a hepatitis E outbreak occurred in Jaipur, probably related to contamination of drinking water due to antiquated pipelines. Hepatitis E virus is transmitted by contaminated food or water. The mortality rate is particularly high in pregnant women. As below, travelers to India should not consume any liquids unless bottled or boiled.

In January 2010, a hepatitis E outbreak was reported from Shimla, the state capital of Himachal Pradesh, related to sewage contamination of water supplies, causing more than 160 cases by February. In August 2007, an outbreak of hepatitis E was reported from Kashmir, resulting in 400 suspected cases (see ProMED-mail , August 6, 2007, and July 16, 2011). An increased number of cases was reported from Mumbai in 2004.

An outbreak of hepatitis A was reported from the Maulana Azad Medical College Delhi in January 2014 and from district of Kerala state in December 2011, during the monsoon season (see ProMED-mail, December 13, 2011). Hepatitis A vaccine is recommended for all travelers to India.

An outbreak of leptospirosis outbreak was reported from the southern part of the state of Gujarat in August 2011, causing more than 700 cases and more than 100 deaths, and from the Malabar area of the state of Kerala in September 2011, causing more than 200 suspected cases (see ProMED-mail). Cases are reported from Gujarat every year during the rainy season, typically affecting the Surat, Navasari, and Valsad districts. In July 2006, a leptospirosis outbreak was reported from Mumbai (Bombay), and in May 2006, an outbreak was reported from Vadaserikara in Pathanamthitta District, Kerala, in the southern part of India. Leptospirosis is characterized by flu-like symptoms and rash, sometimes complicated by meningitis, jaundice or kidney failure. The infection is acquired by exposure to water contaminated by the urine of infected animals. In India, the animal reservoir includes rats, cattle, rodents, bandicoots, pigs, dogs, and cats. Outbreaks usually occur with the onset of the monsoon season. Most cases occur in farm workers. Those who may be exposed to water potentially contaminated by animal urine may consider taking a prophylactic 200 mg dose of doxycycline, either once weekly or as a one-time dose before exposure. Most travelers are at low risk.

A rabies outbreak was reported from Chennai in April 2011, causing 15 deaths in the first four months of the year, compared to 12 deaths for all of 2010 and 13 deaths for 2009 (see ProMED-mail, April 21, 2011). Travelers to India should avoid contact with stray dogs, who are the most common source of rabies in India.

A measles outbreak was reported in March 2011 from Allahabad, Uttar Pradesh. In September 2008, a measles outbreak occurred in the mountainous Kishtwar district in the state of Jammu and Kasmir. All travelers born after 1956 should make sure they have had either two documented MMR or measles immunizations or a blood test showing measles immunity. Those born before 1957 are presumed to be immune. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles or MMR vaccine before traveling to India.

A malaria outbreak was reported from the state of Haryana in October 2010, chiefly affecting Bhattu Kalan. A steep increase in the number of malaria cases was reported from the western part of the state of Rajasthan in September 2010. A malaria outbreak was reported from Mumbai in July 2010, causing thousands of cases and 137 deaths as of March 2011, chiefly in central Mumbai, where a large number of construction projects were under way. As of June 2011, cases were still being reported from Mumbai, chiefly from Andheri and nearby areas. Cases of malaria were reported from Kerala in July 2010, several years after it had been officially eradicated in the state. A malaria outbreak was reported in April 2010 from Karnataka, an area usually thought to represent a relatively low risk for the disease. Malaria prophylaxis is recommended for all parts of India, except high-altitude areas.

Twelve cases of malaria were reported between December 2006 and February 2007 among European travelers to Goa, which had previously been thought to be a low risk area for the disease. Most travelers had visited beach resorts north of Panaji. All cases were caused by Plasmodium falciparum, the species which causes the most severe illness. The outbreak appeared to coincide with a period of intense rainfall (50% above average) in the Goan and Konokan region beginning in October 2006, leading to proliferation of mosquitoes. During the same time period, an increased number of malaria cases was observed among the indigenous population. In January 2008, a case of malaria was reported in a Swedish woman who had visited Candolim beach in Goa, indicating ongoing risk. Two more cases were reported in European travelers in January 2009. An increase in the number of cases among local residents was reported in 2012. See Eurosurveillance , ProMED-mail and TropNetEurop for details. Malaria prophylaxis with Lariam (mefloquine), Malarone, or doxycycline is recommended for all travelers to Goa.

Malaria outbreaks are regularly reported from the northeastern state of Assam, usually in the spring. An outbreak which began in April 2006 had caused approximately 500 deaths by June (see ProMED-mail , April 20 and May 7, 2006). A malaria outbreak was also reported from the neighboring state of West Bengal in June 2006, affecting more than 18,000 people, including 55 deaths (see ProMED-mail , June 27, 2006). In June 2005, a malaria outbreak related to heavy rains, which amplified the mosquito population, involved more than 10,000 people in Assam and caused at least 25 deaths (see ProMED-mail , June 4, 2005). Malaria outbreaks were also reported from Assam in the summers of 2001 and 2002, the latter involving more than 40,000 people (see The Lancet Infectious Diseases and ProMED-mail , June 5, 2001). An increased number of malaria cases was reported from Rajasthan in July 2007, chiefly the western part of the state. See ProMED-mail (July 17, 2007; April 26, May 18, and July 14, 2010) for further information.

Outbreaks of acute encephalitis syndrome are being reported annually from the states of Uttar Pradesh, Bihar, and Assam. Some of these cases have been shown to be caused by Japanese encephalitis, but the cause of many cases has not been determined to date. An outbreak of acute encephalitis was reported from the Muzaffarpur district in Bihar in June 2014, causing almost 190 fatalities, chiefly in children, by the end of the month.

In the summer of 2009, an outbreak of acute encephalitis syndrome caused more than 4000 cases and 567 deaths in Uttar Pradesh and 164 cases and 78 deaths in Assam. Between April and December 2010, an additional 3754 cases and 541 deaths were reported from Uttar Pradesh and Bihar, chiefly from Gorakhpur. Cases were also reported from neighboring Nepal. A fresh outbreak of acute encephalitis syndrome was reported in July 2011. As of December 2011, more than 3000 cases and more than 600 deaths had been reported from Uttar Pradesh, chiefly Gorakhpur, and more than 1000 cases and 92 deaths had been reported from Bihar, chiefly Gaya. As of September 2011, there were 1308 cases (246 fatal) in Assam, 404 cases (13 fatal) in Tamil Nadu, and 341 cases (10 fatal) in West Bengal. In Assam, Sivasagar district was particularly affected. A new series of outbreaks were reported in June 2012, causing 588 deaths in Uttar Pradesh (chiefly Gorakhpur and other areas in the eastern part of the state), more than 300 deaths in Bihar, and 20 deaths in Assam (mostly Sivasagar district). For the year 2013, more than 2000 people in Uttar Pradesh required hospital admission for encephalitis and there were 479 fatalities. As before, some but not all of these cases were caused by Japanese encephalitis virus. For further information, go to ProMED-mail . An outbreak of encephalitis of unknown cause was reported from Gujarat in July 2010. Preliminary data indicate the cause may have been Chandipura virus (see ProMED-mail , August 5 and 7, 2010).

Outbreaks of Japanese encephalitis occur annually, particularly in the states of Uttar Pradesh and Assam in the northern p
art of India. Cases are also reported each year from Bihar. The latest outbreak occurred in Assam in August 2014, causing more than 1200 cases and 350 deaths. The district of Sivasagar was particularly affected. A smaller outbreak was reported around the same time from Meghalaya state. Japanese encephalitis vaccine is recommended for long-term (greater than 1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips.

Outbreaks of Japanese encephalitis were reported from Uttar Pradesh in June 2012, causing 129 deaths, from Assam's Sivasagar district in July 2012, and from Odisha's Malkangiri district in November 2012, killing at least 24 children. In August 2011, an outbreak was reported from Assam, causing more than 350 cases and nearly 90 deaths. At around the same time, an outbreak occurred in Bihar, chiefly involving the city of Gaya and causing 84 deaths as of November. An outbreak was reported from Ranchi in Jharkhand state in September 2011, causing 36 cases, 12 of them fatal. In September-October 2011, an outbreak occurred in Mahrajganj district in eastern Uttar Pradesh, killing at least 40 children. A small number of cases were also reported from Delhi in between September and December 2011.

An outbreak of Japanese encephalitis was reported in July 2010 from Manipur, resulting in 34 confirmed cases and many more suspected cases. In May 2009, an outbreak was reported from the eastern part of Uttar Pradesh and neighboring areas. In July 2008, an outbreak of Japanese encephalitis caused more than 2400 suspected cases and 447 deaths in Uttar Pradesh and more than 100 suspected cases and 23 deaths in Assam. In Uttar Pradesh, most of those affected were from the Gorakhpur, Kushinagar, Deoria, Mahrajganj, Sant Kabir Nagar and Siddharthanagar districts. A single case was reported from Kolkata in October 2008, the first in ten years. In July 2007, an outbreak of Japanese encephalitis was reported from the eastern part of Uttar Pradesh, resulting in almost 500 deaths, and from Assam, resulting in 115 confirmed deaths. An outbreak also occurred in eastern Uttar Pradesh in October 2006, causing almost 300 deaths (see ProMED-mail , November 6, 2006; July 28, September 30, and October 26, 2007; and September 18, 2008). In August 2005, a major Japanese encephalitis outbreak was reported from Uttar Pradesh and the neighboring province of Bihar, chiefly among young children and others living in rural areas. More than 6000 suspected cases were identified, almost one-quarter of them fatal. Many of those who survived showed evidence of mental retardation or other neurological deficits. See the World Health Organization , NATHNAC and ProMED-mail (August 26, 2005) for further information. In September 1999, an outbreak of Japanese encephalitis was reported from Andhra Pradesh state, which historically records outbreaks every 2-3 years.

A mixed outbreak of dengue fever and chikungunya fever was reported from the state of Karnataka in June 2014, chiefly affecting Ramanagara district. Mixed outbreaks of dengue and chikungunya also occurred in Tamil Nadu in January 2010, affecting hundreds of people, and in the city of Pune in the state of Maharashtra in November 2010. See ProMED-mail (February 12 and November 11, 2010, June 30, 2014) for further information.

An outbreak of malaria with a high frequency of cerebral involvement was reported from Munger district in the state of Bihar in August 2009 (see ProMED-mail , August 10, 2009). Malaria prophylaxis and insect protection measures are recommended for all travelers to India.

An outbreak of chikungunya fever was reported from India in February 2006. As of March 2007, a total of 32 cases of chikungunya fever had been reported among Americans who had visited India. Fresh cases continue to be reported. Chikungunya fever is a viral infection transmitted by mosquito bites. Symptoms include fever, joint pains, muscle aches, headache, and rash. The disease is almost never fatal, but may be complicated by protracted fatigue and malaise. Rarely, the infection is complicated by meningoencephalitis, which is usually seen in newborns and those with pre-existing medical conditions. Insect protection measures are strongly recommended, as described below. Because of the risk of mother-to-child transmission, pregnant women need to take special care to protect themselves from mosquito bites. For additional information, go to the Chikungunya Fever Fact Sheet on the CDC website.

More than 1.25 million suspected cases were reported in 2006, including more than 700,000 suspected cases in Karnataka and more than 200,000 in Maharashtra. In the first nine months of 2008, more than 70,000 cases were described, mostly in the states of Karnataka (especially Mangalore district) and neighboring Kerala. There was also an ongoing outbreak in West Bengal. Since the outbreak began, cases have also been reported from the states of Andhra Pradesh, Tamil Nadu, Haryana, Madhya Pradesh, Gujarat, Orissa, Government of National Capital Territory of Delhi, Rajasthan, Pondicherry, Goa, and the Andaman and Nicobar Islands. In March 2009, an outbreak was reported from Kothra village of Nandod taluka, Narmada district, Gujarat. An outbreak was reported from Goa in May 2009 and again in July 2009. In June 2009, October 2009, and August 2010, an increased number of cases were reported from Karnataka. In August 2009, an outbreak was reported from the island of Rameswaram in Tamil Nadu state. In September 2009, an outbreak was reported from Keezhakarai and surrounding villages in Ramanathapuram district, Tamil Nadu, and cases were reported from Hyderabad. Between September and November 2010, 25 cases were reported from Mumbai and 41 cases from New Delhi. Outbreaks were reported from Orissa state in December 2010 and again in May 2012, from Goa in January 2011, from Uttar Pradesh in October 2011, from Bihar state and from Delhi in November 2011, from Kerala in December 2011 and March 2012, from Jalpaiguri district in West Bengal in June 2012, from Delhi and from Shinor taluka in Gujarat in October 2012, from Ganjam district of Odisha in January 2013, and from Chennai, Merpanaikadu, and Maaradi village in Tamil Nadu state in September 2014. See the World Health Organization , MMWR , Eurosurveillance , and ProMED-mail for further details.

Outbreaks of dengue fever occur regularly in India. The most recent were reported between August and October 2011 from Delhi, from the ciy of Jaipur in Rajasthan state, from the city of Lucknow in Uttar Pradesh, from the city of Ludhiana in Punjab state, from Thiruvananthapuram in Kerala state, from Hyderabad city in Andhra Pradesh state, from the city of Ahmedabad in Gujarat state, from the city of Chandigarh, and from Orissa state. A much larger outbreak was reported from Delhi in June 2010, causing more than 6000 cases and eight deaths by November. Outbreaks were also reported from Kerala and Assam in November 2010; from Bihar in September 2010, causing more than 500 cases and at least six deaths; from Orissa's tribal-dominated Malkangiri district in August 2010; from Kerala and from Pimpri-Chinchwad in the Pune district of Maharashtra state in June 2010; from Kerala in March 2010, from New Delhi and from Madhya Pradesh in October 2009, and from Gujarat in August 2009. In July 2009, outbreaks were reported from Kolkata (Calcutta) and from Kerala (in the southern part of the country). An outbreak was reported from the campus of the Medical College in Kerala in April 2009 and again in June 2009. An outbreak in 2008 caused more than 2800 cases nationwide, mostly in Haryana, Maharashtra, Tamil Nadu, and Delhi (chiefly West Delhi). As of late September, the number of new cases appeared to be declining, except in Delhi. In October and November, 2008, outbreaks were reported from West Bengal state and from Ludhiana, Mohali, and Bathinda in Punjab state. A major dengue outbreak was reported in September 2006, especially affecting Delhi, leading to 9940 cases and 183 deaths as of mid-November. In June 2003, a major dengue outbreak was reported from Delhi and surrounding areas, resulting in 2185 confirmed cases and four deaths (see the World Health Organization ). A previous outbreak occurred in Delhi from August to November 1996.

Dengue fever is a flu-like illness which is sometimes complicated by hemorrhage or shock. The infection is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are strongly advised, as outlined below. For further information on dengue in India, go to the World Health Organization - South-East Asia Region .

An outbreak of typhoid fever was reported from Jamnagar, Gujarat state, in May 2013. and from Punjab in April 2012. An increased number of cases of typhoid fever was reported in March 2012 from rural areas in central Karnataka. In August 2010, a typhoid outbreak was reported in August 2010 from Panchkula, a city in the northwestern Indian state of Haryana. In June 2007, a typhoid outbreak occurred in the Kangpokpi area of Senapati district, Manipur state. In August 2006, a typhoid outbreak was reported from West Kochi, in the southern part of India, resulting in more than 300 suspected cases (see ProMED-mail ; August 28, 2006. and August 29, 2010).

Cases of typhoid which show increased resistance to quinolones or third-generation cephalosporins, the antibiotics often used to treat these infections, have recently been reported among travelers to India and Nepal, though some strains retain susceptibility to newer quinolones, such as gatifloxacin (see Eurosurveillance and ProMED-mail, October 31 and November 5, 2011). Typhoid vaccine is recommended for all travelers to India.

An outbreak of meningococcal meningitis was reported in January 2009 from the state of Meghalaya in northeastern India. By February 2009, the outbreak had spread to the neighboring states of Tripura and Mizoram and had caused at least 2000 suspected cases and at least 230 deaths. Meningococcal infections are spread person-to-person by exposure to secretions from the nose or throat, and may lead to meningitis, marked by the abrupt onset of fever, headache, stiff neck, and lethargy, frequently with a rash. At the present time, meningococcal vaccine is recommended for all travelers to Meghalaya, Tripura and Mizoram. In May 2005, a meningococcal outbreak occurred in Delhi, resulting in 441 cases and 60 deaths, chiefly in young adults. Most cases were reported from the walled city of Old Delhi, chiefly in Shahdara North, Shahdara South, Sadar Paharganj, Civil Lines, and Central. See the World Health Organization and Health Canada for further information.

An outbreak of hepatitis B , apparently transmitted by physicians who used contaminated needles and syringes, was reported from Sabarkantha district, Gujarat state in February 2009. A total of 92 deaths were identified (see ProMED-mail ). Hepatitis B vaccination is recommended for all travelers to India.

A conjunctivitis ("pink-eye") outbreak was reported from Mumbai in October 2007. Most outbreaks of conjunctivitis are caused by enteroviruses or adenoviruses. In most cases, the illness resolves uneventfully, but may cause significant discomfort and temporary incapacity. Acute conjunctivitis may be prevented by frequent hand washing and by not sharing towels and bedding.

An outbreak of hand, foot, and mouth disease was reported from Calcutta in September 2007 (see ProMED-mail ; September 23, 2007). Most outbreaks of hand, foot, and mouth disease are caused by enteroviruses, which are transmitted by exposure to fecal material from infected individuals. Most cases occur in infants and young children, though adults may also be affected. The illness is characterized by fever, oral blisters, and a rash or blisters on the palms and soles. Most cases resolve uneventfully, but a small percentage are complicated by encephalitis (inflammation of the brain), myocarditis (inflammation of the heart muscle), or pulmonary edema (fluid in the lungs). The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food.

An outbreak of Nipah virus infections was reported in May 2007 from Nadia district in West Bengal state, killing five people (see ProMED-mail ; May 8 and 10, 2007). A Nipah virus outbreak was also reported from West Bengal in January-February 2001, affecting the district of Siliguri (see Emerging Infectious Diseases ). Nipah virus infections begin with flu-like symptoms, including high fevers and muscle pains, which may be followed by inflammation of the brain (encephalitis), resulting in drowsiness, disorientation, convulsions, coma, and death. Most cases of Nipah virus infection occur in those who have had close contact with infected pigs. The disease may also be transmitted from person-to-person, especially in health care settings. Most travelers are at extremely low risk.

Outbreaks of H5N1 avian influenza ("bird flu") were reported from commercial poultry farms in Maharashtra state in February 2006 and from the states of Gujarat and Madhya Pradesh shortly thereafter. The most recent poultry outbreaks have been reported from the northeastern part of the country, near the border with Bangladesh: between January and April 2008 from West Bengal, in April 2008 from Tripura, in November and December 2008 from Assam, from West Bengal between December 2008 and May 2009, from Tripura in March 2011, from Assam in August 2011, and from West Bengal in September 2011. No human cases have been reported from India to date.

Most travelers are at extremely low risk for avian influenza, since almost all human cases in other countries have occurred in those who have had direct contact with live, infected poultry, or sustained, intimate contact with family members suffering from the disease. The Centers for Disease Control and the World Health Organization do not advise against travel to countries affected by avian influenza, but recommend that travelers should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked. A vaccine for avian influenza was recently approved by the U.S. Food and Drug Administration (FDA), but produces adequate antibody levels in fewer than half of recipients and is not commercially available. The vaccines for human influenza do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to India, especially West Bengal, should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization , Health Canada , the Centers for Disease Control , and ProMED-mail .

An outbreak of poliomyelitis was reported in August 2006 from Moradabad district, western Uttar Pradesh. For India as a whole, a total of 674 polio cases were recorded for the year 2006, more than ten times as many as the previous year. A total of 864 cases were recorded for the year 2007, 546 cases in 2008, and 724 cases in 2009. Most of these cases were reported from Uttar Pradesh and the neighboring state of Bihar. For the first nine months of 2010, only 38 cases were described. For the first ten months of 2011, only one case was identified (a case from West Bengal in January). For further information, go to the World Health Organization . At the present time, polio transmission in India is limited to western Uttar Pradesh and the states of Bihar and Uttarakhand. A one-time polio booster is recommended for any adult traveler who received the recommended childhood immunizations but never had polio vaccine as an adult. Children should be fully immunized against polio before traveling to India.

Cholera outbreaks occur frequently in India. The most recent were reported in August 2011 from Maharashtra; in July 2011 from Sarai village, Gujarat; in June 2011 from Kerala; in April 2011 from Yamunanagar district, Haryana; in January 2011 from Mumbai and from Pune in the state of Maharashtra; in October 2010 from Sonitpur district in Assam and from Islamabad district in south Kashmir; in September 2010 from the Rayagada, Koraput, Balangir, and Kalahandi districts in Orissa; in May 2010 from Choranda village in Gujarat and from Theni district in Tamil Nadu; in September 2009 from the Kalbadevi area in Mumbai and from Narmada district in Gujarat; in July-August 2009 from the state of Punjab; and in June 2009 from Tumkur city in the state of Karnataka and from the city of Surat in the state of Gujarat. The city of Delhi reported 732 cases in the first nine months of 2008. In September 2008, outbreaks were reported from Murshidabad in West Bengal and from Valiya taluk in Gujarat. In September 2007, a cholera outbreak occurred in the state of Orissa in eastern India, causing almost 200 deaths, after a typhoon hit the area. At about the same time, a much smaller outbreak was reported from Ambala Cantonment in Haryana. In April 2007, a cholera outbreak occurred in the Bally municipality area of Howrah in West Bengal. In October 2006, a small outbreak was reported from Mumbai. In August 2006, an outbreak was reported from Tibba Village in Nurpur Bedi area of Ropar district. An outbreak in Delhi that began in April 2006 had caused 550 cases as of July. A large cholera outbreak was reported in November 2005 from the southeastern coastal city of Chennai (Madras) after heavy rains and flooding (see ProMED-mail ; November 18, 2005). In July 2001, a cholera outbreak related to flooding was reported from Orissa State, resulting in 34,000 cases and 33 deaths as of mid-August (see the World Health Organization .)

The main symptoms of cholera are profuse watery diarrhea and vomiting, which in severe cases may lead to dehydration and death. Most outbreaks are related to contaminated drinking water, typically in situations of poverty, overcrowding, and poor sanitation. Most travelers are at extremely low risk for infection. Cholera vaccine, where available, is recommended only for certain high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. All travelers should carefully observe food and water precautions, as below.

An outbreak of pneumonic plague (plague involving the lungs) was reported in February 2002 from Hat Koti village, Shimla district, Himachal Pradesh state. As of February 19, a total of 16 cases had been identified, including four deaths. The outbreak appears to be limited to the residents of this village. The risk to travelers appears to be extremely low. The World Health Organization recommends no special restrictions on travel or trade to or from India. For further information, go to the World Health Organization and ProMED-mail . A previous outbreak of pneumonic plague occurred in 1994. Eight states were involved, including Maharashtra (including Bombay), Gujarat (including the city of Surat), Karnataka, Uttar Pradesh, Madhya Pradesh, Haryana, Rajasthan, and West Bengal, as well as the federal district of New Delhi.

Visceral leishmaniasis , a parasitic infection transmitted by sandfly bites, is on the rise in India and has reached epidemic proportions in Bihar State. Large number of cases are also reported from the states of West Bengal and Jharkhand (see ProMED-mail; October 9, 2011). Visceral leishmaniasis causes fever, weight loss, anemia, and enlargement of the liver and spleen developing over months to years. The disease is especially severe among those with HIV. Travelers to Bihar, West Bengal, and Jharkhand should be sure to take steps to protect themselves from sandfly bites, as described below.

Buffalopox was reported in five children from two villages in Beed district, Maharashtra State in March 1998, at the same time that the illness was occurring locally in cattle. The illness in humans is characterized by fever, enlarged lymph nodes and pox lesions on the hands. Three cases of the disease were also reported from Maharashtra State between 1992 and 1994.

Kyasanur Forest disease (transmitted by ticks who have fed on infected monkeys; most cases reported from forested areas in Karnataka State during dry spells; outbreak reported from Karnataka in February 2014, causing 74 cases by April, chiefly in the districts of Shimoga, Chikmagalur and Dakshina Kannada; outbreaks reported from Bandipur Tiger Reserve, bordering Mysore district, in November 2012 and from Shimoga district, in February-March 2012, both in Karnataka state; cases reported from Honnavar taluk in Karnataka in February 2009; outbreaks reported from Chikmagalur, Shimoga, Uttara Kannada, and Dakshina Kannada districts in April-June 2003 and from the Western Ghats region in April-May 2000; see
ProMED-mail
)

Chandipura virus encephalitis (outbreak reported from the eastern districts of Gujarat State in 2004)

Anthrax
(most outbreaks reported from Andhra Pradesh, Karnataka, West Bengal, Tamil Nadu, and Orissa; most cases occur in villagers who have direct contact with infected animals or animal products; outbreaks reported in June 2014 from Odisha state after villagers consumed infected buffalo and goat meat; in June 2013 and May 2014 from Odisha state; from sheep-rearing areas of northern coastal Andhra Pradesh [AP], Godavari districts, and Krishna districts in June 2013; from Murshidabad district in West Bengal in June 2007 and July 2010, from the Koraput district of Orissa and the Nellore area in Andhra Pradesh in February 2008, from Rayagada district in Orissa state and from Prakasam district in Andhra Pradesh in March 2009, from the Visakhapatnam district of Andhra Pradesh in May 2009, from Orissa in June 2009, from the Paschim Medinipur district in West Bengal in May 2010; from Koraput district in Orissa in June 2010; from Kandhamal district in Orissa in June 2011; from Chittoor district in Andhra Pradesh in July 2011; and from Koraput village in Orissa in April 2013; see
Emerging Infectious Diseases
and
ProMED-mail
)

Indian tick typhus (outbreak reported in March 2011 from Lunglei district in Mizoram, causing six fatal cases; outbreak reported in August 2007 from Deol village in Himachal Pradesh, in the far north of the country; see
ProMED-mail
; August 6, 2007, and May 2, 2011)

Typhus
(outbreak reported in July 2007 from the state of Kerala, in the south)

Do not drink tap water unless it has been
boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include
ciprofloxacin (Cipro)
,
levofloxacin (Levaquin)
,
rifaximin (Xifaxan)
, or
azithromycin (Zithromax)
. Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply
insect repellents
containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to
Medical Information for Americans Traveling Abroad
on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal
medical kit
, customized for your trip (see description). Take appropriate measures to prevent
motion sickness
and
jet lag
, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent
blood clots
in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

For a public ambulance in New Delhi, Mumbai, Chennai and Calcutta, call 102. For a private ambulance in Mumbai, call 1299 or 3090-6609, or call P.D. Hinduja National Hospital at 2445-2575 . For a private ambulance in Kolkata, call Apollo Gleneagles Hospital at 1066 or Woodlands Medical Centre at 2456-7075 thru 7089 (cell 98300-82007, 98310-36686, 98302-90662).

For 24/7 emergency assistance, another option is to contact East West Rescue, which provides long-distance road ambulance as well as air ambulance services (website http://www.eastwestrescue.com; ph. 91-11-2469 8865, 91-11-2462 3738, 91-11-2469 9229, 91-11-2469 0429). East West Rescue has a network of physicians in over 100 Indian cities.

Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Life-threatening medical problems may require air evacuation to a country with state-of-the-art medical facilities.

Screening for HIV and hepatitis remains inadequate. In September 2011, an outbreak of HIV infections was reported among children who had received contaminated transfusions at a government-run hospital in the Junagadh district of Gujarat state between January and August 2011. In June 2011, it was announced that the blood from blood banks in Ludhiana city, Punjab state, was contaminated with hepatitis C. In August 2009, it was reported that adulterated blood contaminated with hepatitis B and hepatitis C viruses was being sold for transfusions in Uttar Pradesh. In October 2006, it was reported that outdated blood screening kits had been sold to government clinics across India (see
ProMED-mail
, November 5, 2006, and August 31, 2009). Transfusions in India should be avoided if at all possible.

Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the links under "Physicians and hospitals" above).

All children should be up-to-date on routine childhood immunizations, as recommended by the
American Academy of Pediatrics
. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the
accelerated immunization schedule
).

The recommendations for
malaria
prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.

When traveling with young children, be particularly careful about what you allow them to eat and drink (see
food and water precautions
), because diarrhea can be especially dangerous in this age group and because the vaccines for
hepatitis A
and
typhoid fever
, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.

Be sure to pack a
medical kit
when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

Because of the risk of
malaria
, pregnant women should avoid traveling to India. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to malarious areas is unavoidable,
insect protection measures
must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.

Strict attention to
food and water precautions
is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

U.S. citizens living in or visiting India are encouraged to register at the U.S. Embassy in New Delhi or at one of the U.S. consulates in India. They may now also use the
Department of States new Internet Based Registration System
to register. To register online, please visit https://travelregistration.state.gov/ibrs.

-- The
U.S. Embassy in New Delhi
is located at Shantipath, Chanakyapuri 110021; telephone (91)(11)2419-8000; fax (91)(11)2419-0017. The Embassy's Internet home page address is http://newdelhi.usembassy.gov.

-- The
U.S. Consulate General in Mumbai (Bombay)
is located at Lincoln House, 78 Bhulabhai Desai Road, 400026, telephone (91)(22) 2363-3611; fax (91)(22) 2363-0350. Internet home page address is http://mumbai.usconsulate.gov.

--
The U.S. Consulate General in Calcutta
(now often called Kolkata) is at 5/1 Ho Chi Minh Sarani, 700071; telephone (91)(33) 2282-3611 through 2282-3615; fax (91)(33)2282-2335. The Internet home page address is http://calcutta.usconsulate.gov.

-- The
U.S. Consulate General in Chennai (Madras)
is at 220 Anna Salai, Gemini Circle, 600006, telephone (91) (44) 2811-2000; fax (91)(44)2811-2027. The Internet home page address is http://chennai.usconsulate.gov.